Provider Demographics
NPI:1871927517
Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Entity type:Organization
Organization Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:601-545-8700
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-3700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:64 OLD AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8382
Practice Address - Country:US
Practice Address - Phone:601-450-5661
Practice Address - Fax:601-544-8627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06374/ 5.23336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06374/5.2OtherPERMIT# 06374/5.2 - (LIMITED CLOSED DOOR)
MSCS06374/5.2OtherCONTROLLED SUBSTANCE REGISTRATION